Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Margaret Dexheimer Pharris, PhD, RN, MPH, FAAN


Doctor of Nursing Practice


Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are surgical procedures performed for painful, dysfunctional joints most often caused by osteoarthritis. These procedures are increasing in demand for not just the elderly, but young adults as well. They are elective procedures associated with a three to five gram decrease in hemoglobin postoperatively, considered a major blood loss. International research results, verified by analysis of a 228 patient sample from the system in this study, demonstrate that patients who enter these procedures with anemia are more likely to require postoperative blood transfusions. With a decreasing supply due to a shrinking donor pool and added costs due to stringent testing, allogeneic blood used for transfusions demands that providers use stewardship with this precious resource. Autologously donated blood as an option is falling out of favor because it further reduces the preoperative hemoglobin, is costly, and unused units are wasted. Blood use for transfusions, whether autologously donated or allogeneic, is associated with many risks including but not limited to fluid volume overload, delayed wound healing, postoperative infections, and longer hospitalizations. Anemia is an abnormal finding and, in the setting of elective surgical procedures with major blood loss, should be corrected preoperatively to decrease the need for blood transfusions. This change project describes interventions to increase red blood cells preoperatively, weaving the interventions into an evidenced-based algorithm for consideration in practice by members of the healthcare team. The evidence-based algorithm and study findings will be shared with providers to invoke discussion on strategies for implementation and evaluation. Furthermore, this project serves as an example of research-guided changes, designed by a doctorally prepared nurse, capable of enhancing positive health care outcomes for both the patient and the healthcare system.